Patient Information

Philip Harrop, age 26

Opening Line: Can you do me a sick note for work?

History: You just need a sick note for your job, for stress. You have had a lot going on recently and it has gotten on top of you. You feel stressed all the time. So far you have had the last week off work with stress - you have self certified - you drive a van for an electronics company, but you know your boss won’t let you self certify.

Information to divulge if asked: You were caught driving under the influence of alcohol around 3 months ago, and were banned from driving in court three days ago. Unfortunately your job is driving - you deliver electrical goods from the suppliers to local businesses so you can’t go to work. If you tell your employer about the conviction you will probably be fired - you have only been working there about 8 months, and you really need the job. Your stress only really started when you got banned. You know the doctor can write a sick note for work, but you don’t want the driving ban or alcohol problem to be on there. You are hoping it can say stress (or if the doctor is unwilling to put that down, then anything else would do), so long as it’s something that won’t get you in trouble. You need the sick note to be 3 months long, as that is your ban.

You had gone to the pub as you normally do after work on Friday night and you probably had about 8-10 pints of lager. If you are being honest you do drive home after because it is literally only a mile away. It was so unlucky that you got caught and breathalysed this time. You don't know what the big fuss was about anyway, as you can hold your alcohol well, and are probably safer than 90% of drivers out there, even after a few pints. You have no previous convictions. You have already agreed to see the alcohol support team locally as it reduced your ban from 6 to 3 months.

You have no symptoms of depression, your mood is fine, you don't feel hopeless, you have no suicidal ideations, you look forward to plenty of things, like nights out etc..

Social: You know the nurse told you when you registered that you drink too much alcohol but in your opinion you only drink Friday and Saturday, never through the week. Its the only time you get to relax with your mates. Outside of work you have a long term girlfriend but she is doing a midwifery course in Sheffield so you don't see her as often at the moment. You have no children. You do smoke, about 5-6 a day. You are not bothered about stopping.

Ideas: you need a sick note as you cannot work

Concerns: you do not want your conviction listed as the reason for your absence on the form, you would like the doctor to write stress or anything else that will work.

Expectations: that the above will not be an issue, after all it is only for three weeks

How to respond: Despite what the doctor says, You will not walk out the door without a sick note. If they say they can’t do a sick note for stress, then you will ask them : “what can they do a sick note for? - when they give an example, you will make up symptoms to fit that diagnosis - i.e. chest infection etc... If the doctor simply refuses to do a note with no explanation, you get very angry because you will lose your job and it will be the doctors fault! You will not leave without a note saying something! You will accept a short note, with a review, and any stress management that is offered.

Demeanor: You will initially be calm and complementing to the doctor, you will try every trick in the book to get a note, you will try sucking up to the Dr, then try being angry if that doesn't work etc...

Examination Findings

Examination

Not strictly needed in this case: but if asked:

Pulse 69BP 129/80RR 18Chest clear to auscultate

Appears well dressed, smiling, open body language, speech is of normal pace, not pressured nor slow. Not fidgety, or slow in movements. Maintains good eye contact throughout.

Mark scheme

Data Gathering

POSITIVE INDICATORSOrganised and systematic in gathering information from history taking, examination and investigationIdentifies abnormal findings or results and/or recognises their implicationsData gathering does appears to be guided by the probabilities of disease

Asks about complaint and explores patients understanding of the condition

Explores patients' concern regarding the sick note.

Enquirers about symptoms of depression and performs a risk assessment.

NEGATIVE INDICATORSMakes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Fails to identify abnormal data or correctly interpret them

Fails to ask about symptoms of depression, or fails to perform a risk assessment.

Clinical Management Skills

POSITIVE INDICATORSDevelops a management plan that is appropriate andin line with current best practiceMakes appropriate decisions regarding sick note

Is truthful on the sick note.

Offers advice re stress, or referral to stress management services.

Offers close follow up.

NEGATIVE INDICATORSFollow-up arrangements are absent or disjointed

Colludes with the patient - lies on the sick note.

Does not discuss stress management or offer services to aid stress management.

Makes inappropriate decisions re sick note.

Inter Personal Skills

POSITIVE INDICATORSIdentify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues.Works with the patient to develop a shared management plan or clarify the roles of doctor and patientUses explanations that are relevant and understandable to the patientShows sensitivity for the patient’s feelings in all aspects of the consultation

Is not judgemental towards patient's situation

NEGATIVE INDICATORSDoesn't enquire about patients ICETakes a doctor centered approach towards managementUses an explanation that is filled with jargon, or forgets to explain at allDoesn't show any sympathy / empathy towards the patient's situationFails to empower patient

appears judgemental towards patient's situation

Management

Management:This is a very tricky case! But one that you may encounter from time to time. It may not just be drink driving, but may be other convictions that would affect peoples livelihood, and they may come to you for help.

In reality there is no just one right answer in this case, but there are some wrong ones! Firstly, you can not collude with the patient. You can not give him 3 months off just to cover up his driving conviction. Secondly, you can not lie on a MED3 (sick note) form.

This case is about discussion with the patient, and coming to an agreed action plan. It is possible that the threat of losing his job has made him stressed, so he may need a little time to get to terms with this. You could suggest that he use this time to undertake stress management courses. A sensible compromise would be a few weeks, with regular review to gauge progress. You must make it clear to the patient that you can not say something that isn't true on the MED3 form.

Also known as the "fit note" or more commonly: the "sick note". Introduced in April 2010, it replaced the old 'sick note / fit note'. For the first 7 days the patient does not need a med3, they should self certify. If the employer wants a 'sick note' during this time the GP has a right to charge for this.[1]

Med3 can be used to declare the patient as either 'not fit for work' or 'may be fit for work'. Always consider whether they may be fit for work before declaring them unfit outright. A Med3 can only be issued after the patient has been seen by yourself, and can not be backdated unless it was to a period of prior assessment.[2]

If the patient does not need time off work, then the employer can not demand a 'fit note' as proof of fitness to work. The employee no longer needs a 'fit note' to go back to work either, and may return to work before the end date specified on the med3. If you declare someone as 'may be fit for work' if certain circumstances are met, but the employer can not meet these demands, the med3 already issued can be used as a 'not fit for work' note, there is no need to issue a new Med3. [3]

What you put down in the 'diagnosis' box - "should be as accurate a diagnosis as possible, unless you consider that providing a precise diagnosis would be harmful to your patient's wellbeing or compromise your patient's position with their employer" [4]

No longer in use

Med 4, Med 5, Med 6 and RM7 have now all been withdrawn from use.

CSA Revision; owned and operated by LaneApps Limited, No: 08950053

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